Stubbing Out Cigarettes at the Hospital

Convincing people to stop smoking is no easy task, as family members or friends of smokers know all too well. But consider a situation where roughly three-quarters of active smokers find themselves ready to quit, willing to make that all-important first step of deciding to go smoke-free. When is this short window of vulnerability and motivation open? The time is when a smoker is in the hospital, said Dr. Lisa Shah, instructor in the section of hospital medicine at the University of Chicago Medical Center, a time when the patient is also surrounded by the infrastructure needed to nurture a desire to stop smoking into a successful change of behavior.

But Shah, a researcher focused on studying inpatient tobacco cessation, said in her Medicine Grand Rounds presentation Tuesday afternoon that many doctors miss this opportunity to help their patients kick a dangerous habit. In fact, it was right there on a slide titled The Missed Opportunity, which laid out why inpatients find themselves ready to quit: the no-smoking policies in place at hospitals*, the shock of being hospitalized for an illness that may be a direct result of smoking, and the isolation from environmental cues at home or work that may trigger the urge to smoke.

“For the smokers we see here, often one big barrier to quitting smoking is that they have family members and friends who also smoke cigarettes, Shah said. “Social smoking is a huge impetus to smoke, and makes it hard to quit. So hospitalization helps them succeed in quitting smoking without the temptation.”

“Acute hospitalization also represents a health shock,” Shah continued. “When people are admitted to the hospital and sick with a heart attack or pneumonia, it gives them time to reflect on life and the fact that they’re actually ill. They want to do something about it, and are more likely to make a behavioral change at this moment.”

Statistics support the idea that intervening with a smoker while they’re hospitalized is effective. A 2008 study found that in-hospital counseling and a month of post-discharge clinical support led to an astounding 65% quit rate a year after discharge. Consider that the “cold turkey” method only has about a 12% quit rate, and drug therapies are at most 33% successful, that’s an encouraging figure.

But when Shah did a study of whether physicians capitalize on this opportunity, she found that many merely advised their patients to quit without offering to enroll them in a smoking cessation program. Quitting advice was dispensed in 60% of the cases she studied, but only half of those were enrolled in a formal cessation program, and only 4% were given prescriptions for drugs such as Chantix or Zyban to help them quit.

More abstractly, but no less important, most patients on discharge believed that going “cold turkey” was as effective as nicotine replacement therapy or drug therapy, suggesting that they weren’t always receiving the proper medical information to help them quit. When physicians were surveyed about why they often didn’t refer patients to formal smoking cessation treatment, Shah found that many didn’t think they had time to offer counseling on the topic, or didn’t consider the patient’s cigarette habit to be a top priority while they were in the hospital.

“It’s very fair for clinicians to say they don’t have time given the other pressures they face,” Shah said. “They’re very concerned with the acute issue at hand, and while it might be related to smoking, that’s not the direct issue that they need to address in their minds.”

But that attitude may be changing. A bill currently being considered by the Illinois State Legislature would broaden the types of cessation treatments covered by Medicaid, which may allow hospitals to hire smoking counselors. Another recent study, from researchers at Northwestern University, found that smoking cessation is rarely recommended by doctors in mental health patient populations as well, and recommends that cessation be incorporated into mental health plans. And Shah points out that current health care demands are leading hospitals to change their philosophy about what issues should be dealt with during a hospital stay.

“The hospital is traditionally meant to treat the acute illness, while things like smoking and immunizations were largely done in outpatient setting,” Shah said. “The hospital has not been seen as the route to deal with preventive measures, but with costs of health care on the rise and prevention becoming more important, we’re realizing a lot of things that we were relying on the outpatient setting for are very important for inpatients.”

(* – All American hospitals are currently non-smoking, but when Shah and her colleagues used a device that tested whether patients had recently smoked a cigarette, only 80% were found to be tobacco-free. That means one out of five patients were venturing outdoors to smoke…or sneaking a cigarette in the bathroom.)